Western Michigan University Western Michigan University

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Master's Theses Graduate College

4-2005

Survey of Current Occupational Therapist Practice in the Survey of Current Occupational Therapist Practice in the

Emerging Field of Home Modification and Barrier Free Design Emerging Field of Home Modification and Barrier Free Design

Christian Michael Petrovich

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SURVEY OF CURRENT OCCUPATIONAL THERAPIST PRACTICE IN

THE EMERGING FIELD OF HOME MODIFICATION AND BARRIER FREE DESIGN

by

Christian Michael Petrovich

A Thesis Submitted to the

Faculty of The Graduate College in partial fulfillment of the

requirements for the Degree of Master of Science

Department of Occupational Therapy

Western Michigan University Kalamazoo, Michigan

April 2005

SURVEY OF CURRENT OCCUPATIONAL THERAPIST PRACTICE IN THE

EMERGING FIELD OF HOME MODIFICATION AND BARRIER FREE DESIGN

Christian Michael Petrovich, M. S.

Western Michigan University, 2005

OBJECTIVE

We conducted a national survey of occupational therapists to ascertain what

current trends are taking place in the field of home modification and barrier-free design

and to examine how occupational therapists view their role in the practice of home

modification and barrier free design.

METHODS

A 16-question survey was developed and included two hundred and fifty US

licensed and or registered occupational therapists randomly selected from the AOTA

membership listing.

CONCLUSIONS

The role of occupational therapy in the emerging practice of home modification

and barrier -free design is regarded as important by occupational therapists in the United

States. Many occupational therapists are involved with home accessibility considerations

with their clients. More workshops should be made available for continuing education.

Also, more outcome studies need to be performed to ensure quality outcomes and to

ensure the reliability and validity of current assessment tools.

ii

ACKNOWLEDGMENTS

I would like to begin to give thanks for the many people that have helped me

finish my Master s Thesis. I would like to thank the members of my committee, Dr.

Debra L. Hazel, Dr. Paula W. Jamison, Joseph Smolarkiewicz for taking the time to

answer my questions and reviewing my work. I would like to extend my special

appreciation to Dr. Debra L. Hazel for giving me guidance so that I may complete

this work

Christian Michael Petrovich

Copyright by Christian Michael Petrovich

2005

TABLE OF CONTENTS

ACKNOWLEDGMENTS...................................................................................................ii

LIST OF TABLES..............................................................................................................vi

LIST OF FIGURES...........................................................................................................vii

CHAPTER

I. INTRODUCTION...............................................................................................1

Background of the Study.............................................................................1

Statement of the Problem.............................................................................3

Purpose of the Study....................................................................................3

Definition of Terms......................................................................................3

Significance of the Study.............................................................................5

Outline of the Study.....................................................................................5

II. LITERATURE REVIEW....................................................................................7

Introduction..................................................................................................7

Home Modification Assessment Tools........................................................7

The Housing Enabler...................................................................................9

The Safety Assessment of Function and the Environment for Rehabilitation (SAFER).............................................................................11

The Canadian Occupational Performance Measure (COPM)....................13

The Effectiveness of Occupational Therapy for Home Modification Recommendation.......................................................................................16

Legislature..................................................................................................18

Americans With Disabilities Act of 1990......................................19

Medicaid........................................................................................20

TABLE OF CONTENTS-Continued

No-Fault Law.................................................................................21

Lifetime Homes Concept...............................................................22

Research Question.....................................................................................24

III. METHODOLOGY..........................................................................................25

Introduction................................................................................................25

Review of the Research Question..............................................................25

Sample Demographics...............................................................................26

Survey Instrument......................................................................................26

Data Collection and Analysis.....................................................................28

IV. FINDINGS.......................................................................................................28

Survey Results...........................................................................................28

Discussion of Findings...............................................................................32

V. DISCUSSION AND SUMMARY...................................................................35

Limitations of the Study.............................................................................35

Conclusions and Recommendations..........................................................35

Summary....................................................................................................36

APPENDICES

A. Survey Instrument................................................................................37

B. Assessment Tools Reviewed................................................................39

C. Web Resources.....................................................................................41

D. Survey Data Collection Sheet..............................................................42

E. Cover Letter...........................................................................................44

TABLE OF CONTENTS-Continued

BIBLIOGRAPHY..............................................................................................................45

LIST OF TABLES

1. Number of Assessments Performed Per Year ...... .31

LIST OF FIGURES

1. Lifetime Homes 16 Design Standards ......23

2. Setting of Practice .........28

3. Prepared for Practice ...... ...29

4. Satisfaction with Current Knowledge..........................................................................30

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CHAPTER 1

INTRODUCTION

Background of the Study

The number of people who are disabled or elderly is increasing. According to gerontology

experts, this amount will grow dramatically within the next three decades. From 1990 to 2020, the

number of people over 65 is likely to increase to 54 million. According to U.S. census figures, by

the year 2020, approximately one in six Americans will be 65 or over, and the amount of those 85

or older is expected to double that of 1990 (Johansson, 2003). The growing population of people

65 or older and those with disabilities are facing many constraints within their living environments.

More than 1.8 million Americans reside in institutions, with the vast majority living involuntarily in

skilled nursing facilities (SNF). Millions more are isolated in their homes due to lack of essential

community services, with more than two million considered at risk for entering an institution in

order to receive needed care (U.S. Department of Health and Human Services, 2000 & 2001).

The increase in people 65 and over or who are disabled and interested in living in the

community is occurring as a direct result of improved health care and the desire to age in place.

Growing awareness of the expense and negative effects of institutionalization has also drawn

attention towards the benefits of aging in place. The shift of health care to client-centered and

community-based services has been stimulated by both consumer demands (Gage, 1995) and

legislation (Law et al., 1996). While achieving accessibility may mean finding a new residence or

designing and building a home to the specifications that meet the needs of a person with a specific

disability, it is often possible to adapt or modify current and existing housing using various assistive

technologies. A direct relevance for occupational therapy s role in the field of home modification

and barrier free design has been defined. Occupational therapists are frequently called upon to

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assess the functional fit of housing for clients with limitations. People with limitations require

barrier-free residences that are responsive to their needs and enable them to function in situations

related to employment, recreation, education and other necessary services (Taira, 1984). A well-

designed physical housing environment may contribute to self-maintenance (Rubinstein, 1989),

strong feelings of independence, mastery (Reizenstein & Ostrander, 1981), and psychological

wellbeing (Lawton, 1986).

A survey of 500 adults age 60 and older revealed that 90% rated caring for oneself and

being able to live independently in one s own home as the most important factors of aging. This

survey was commissioned by The Fund to Promote Awareness of Occupational Therapy and

underwritten by Marsh Affinity Group Services (2003). "Occupational therapy is in a unique

position to help people transition to old age. The Baby Boomers, as a population that is well-

educated about health care, will increase the demand for therapeutic services that help them stay at

home longer. They won t be satisfied with an institutional life," said Barbara L. Kornblau, JD,

OT/L, FAOTA, president of AOTA (2003). Occupational therapists must be able to accurately

assess client s capabilities and compatibility with their home environment. Occupational therapy is

skilled treatment that helps individuals achieve independence in all facets of their lives. It gives

people the "skills for the job of living" necessary for independent and satisfying lives. (AOTA

2005). This requires that the therapist is aware of the client s condition and needs, current laws and

legislation, has a valid and reliable assessment tool, and can access community resources as needed.

Environmental attributes interact with human capabilities to enable performance, while

others present barriers to an individual s attempts at meaningful interactions with his or her

surroundings. Occupational performance is the result of complex interactions among person,

environment, and occupation (Christiansen & Baum, 2005, pp. 300). Housing accessibility directly

correlates with a person s ability to perform activities of daily living.

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Statement of the Problem

Occupational therapists work is focused on occupational performance and participation, or

the point when and where the person, the environment, and what the person wants and needs to do

intersect (Christiansen & Baum, 2005, pp. 243). Occupational therapists are involved in the field of

home modification and barrier free design. However, there appears to be a lack of accepted

protocols, evaluation tools, and outcome studies on these procedures to support the expected growth

for occupational therapy in this field.

Purpose of the Study

To improve our understanding of the current occupational therapy practice in the

field of home modification and barrier-free design and foster future research, we conducted a study.

The purpose of this study was to learn about current trends that are taking place in the field of home

modification and barrier free design and to examine how occupational therapists view their role in

the practice of home modification and barrier free design.

Definition of Terms

Occupational therapists are required to follow The Standards of Practice for Occupational

Therapy (AOTA, 1995) as well as the Occupational Therapy Code of Ethics (AOTA, 1998). The

goal of occupational therapy is to enable individuals to achieve competency and satisfaction in

life s chosen roles and in the activities that support function in these roles. An occupational

therapist must be able to evaluate and address certain performance areas, components, and contexts

that influence an individual s ability to achieve independence (AOTA, 1994). The occupational

therapist evaluates the client s occupational function. Following identification of the issues of

difficulty in occupational function, the therapist completes further assessments to determine what

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factors limit performance. If the limiting factors can be improved or eliminated by direct

intervention, the therapist chooses an intervention approach that is appropriate to the problem. The

correct assessment tool is imperative in this decision-making process. During our search for home

modification assessment tools we have come across many evaluations, checklists, surveys, and

assessments. Many of these look at home safety and offer simple and basic solutions, but few have

proven validity and reliability. An assessment should also lead to valid and reliable

recommendations. In the area of home modification and barrier-free design the occupational

therapist may be a part of a team of professionals working with a client. The Person-Environment-

Occupation-Performance Model may help the occupational therapist build a collaborative plan with

the client and other professionals as the client seeks the knowledge and skills of the occupational

therapist to address issues that impact occupational performance (Christiansen & Baum, 2005). As

professionals, occupational therapists should be using assessment tools that have both psychometric

properties as well as sound clinical utility (AOTA, 2004).

Psychometric properties are those aspects of test development and evaluation that are

essential to ensure that an assessment is appropriate for a particular client group, provides reliable

and valid information, and is administered and interpreted in a consistent and ethical manner

(AERA, 1999; Nunnally & Bernstein, 1995). The use of non-standardized checklists is not

recommended because of their inherent lack of evidence of reliability and validity. The tasks listed

in non-standardized checklists are rarely even operationally defined, the initial step in establishing

reliability and validity (Trombley & Radomski, 2002, chap. 36). Evaluation instruments should be

valid, reliable, and responsive enough to detect important changes (Law & Letts, 1989). A reliable

assessment is one that measures the attribute under study consistently no matter who performs it

(interrater reliability) or when the assessment occurs (test-retest reliability). A valid assessment is

one that measures what it purports to measure (Hasselkus & Safrit, 1976). Clinical utility, also an

important part of an assessment, refers to ease and efficiency of use of an assessment, and the

relevance and meaningfulness, clinically, of the information that it provides (Law, King, & Russell,

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2001; Letts et al., 1999). There are many home modification assessment tools available. Some of

the assessments appear to be comprehensive and easy to use. However, there are few with

published studies that have examined reliability, validity or clinical utility.

Significance of the Study

There is currently an increase in the elderly and disabled population in the United States.

The elderly population is projected to double in size to well over 70 million by 2025 (Lawler,

2001). The home is uniquely important in addressing a client as a whole in that it is the one factor

that may encompass all or part of one s performance areas, components, and contexts. It is often

possible to build environments that are barrier-free or to adapt and modify existing housing using

various assistive technologies. In order to improve occupational therapy practice in the field of

home modification and barrier free design, an accepted protocol for evaluating and making

recommendations for modifications is needed. To do this, outcome studies to examine protocol

effectiveness for evaluation tools and recommendation practices need to be conducted. Evaluation

tools along with effective recommendation policies need to be psychometrically sound. We

decided to address these issues by examining the current occupational therapy practice of home

modification and barrier free design.

Outline of the Study

Chapter II continues with a review of the literature focused around the use of valid and

reliable evaluations, outcome studies that have been conducted to demonstrate the effectiveness of

occupational therapy recommendations for home modification, and literature concerning

occupational therapists knowledge relating to home modification and barrier free design. Chapter

III is a description of the research design and implementation. Chapter IV presents the findings

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from the survey and analysis of the findings. The study concludes with a summary, implications of

the findings, and recommendations for future study in Chapter V.

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CHAPTER II

LITERATURE REVIEW

Introduction

A review of the occupational therapy literature on barrier-free design identified a lack of

related occupational therapy research on the topic of the development and use of environmental

assessments (Cooper, Cohen, Hasselkus 1991). The same can be said of outcome studies conducted

to demonstrate the effectiveness of occupational therapists recommendations and knowledge of

home modification related legislature. In order operate most effectively for our clients,

occupational therapists should possess valid and reliable assessment tools, valid research to support

our recommendations and a basic awareness of legislature relating to barrier free-design (AOTA,

1995). Laws may determine how much financial assistance a client may receive, and there are

public building codes that include standards, dimensions and characteristics for many

recommendations relating to home modification and barrier free-design (AOTA, 1995).

Home Modification Assessment Tools

In our research we have come across only three assessment tools used during the home

modification assessment process that have had a published study that reveals the assessments

reliability, validity and clinical utility. The Housing Enabler and the Safety Assessment of Function

and the Environment for Rehabilitation (SAFER) were developed as home modification

assessments. The third assessment, the Canadian Occupational Performance Measure (COPM) was

not developed as a home modification assessment. However, the data obtained from this

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assessment provides specific information regarding occupational performance issues and indication

of the client s perception of importance and satisfaction with occupational performance as well as

any change that has occurred (Toomey, Nicholson & Carswell, 1995). This allows for the therapist

to determine possible modifications that can be made to fit a specific clinical situation. More

research needs to be done to insure that evaluation assessments are valid and reliable. Major

occupational therapy texts and practice sources illustrate that environmental assessments are viewed

by the profession primarily as situation specific and centered on the home. A list of home

modification assessment tools that were reviewed for this study along with author or source are

listed in Appendix B.

An informal survey consisting of identical questions and formatting to that of this study was

conducted by Joe Smolarkiewicz, OTR, and licensed contractor at the 2003 AOTA conference in

Washington D.C. This survey included 24 occupational therapists who were attending a home

modification workshop; their responses revealed that only one of twenty-four surveyed

occupational therapists admitted to having used an assessment tool that has published reliability and

validity. All other responses revealed that occupational therapists are using custom made

assessment tools that do not have any published evidence that addresses the assessments reliability,

validity and clinical utility. This survey also revealed that of those who list a home assessment tool

or tools they have used within the past year all with the exception of one answered being either

dissatisfied or neutral towards how satisfied they were with their current assessment tool. One

therapist reported satisfaction with their assessment tool and that they were using an assessment

that had good psychometric properties. This survey also revealed that the same therapist that

reported satisfaction with using an assessment that had good psychometric properties also felt that

their home assessment tool provided adequate data that communicated effectively across disciplines

(i.e. physicians, architects, builders, clients) to provide justification for implementation and for

funding of home modifications. That same respondent, along with one other of the surveyed

therapists, responded yes to having been involved with an outcome study or follow up study

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assuring proper implementation and follow through with recommendations for home modification

and barrier free design.

The Housing Enabler

The Housing Enabler is one home modification assessment tool currently being used by

occupational therapists that has published reliability, validity and clinical utility. The Housing

Enabler, developed in Sweden, is a detailed tool for norm based objective assessment of the

housing environment and the immediate outdoor environment (Iwarsson, 1999; Iwarsson & Slaug,

2000). The Enabler instrument is comprised of three parts.

The first portion is the assessment of functional limitations and dependence on mobility aids.

By a combination of observation and interview, functional limitations and dependence on mobility

aids are assessed as present or not present. There are 13 items for perceptual and physical

functional limitations and two items for dependence on mobility aids. Profiles of functional

limitations can be described on individual or group level.

Secondly, comes an assessment of the physical environment. Details in the environment are

framed as items and every item is assessed as present or not present. The environmental details are

to the fullest possible extent linked to legislation, regulations or general recommendations.

Lastly, an accessibility score is calculated. The assessment of functional limitations related to

the assessment of physical environment. For each environmental item, the instrument comprises

predefined points (1 to 4), as measures of the severity of the problems predicted to arise in the

relation to each of the functional limitations. The sum of all the points is a measure of the degree of

accessibility problems. The higher the score, the greater the accessibility problems (Iwarsson,

1999; Iwarsson & Slaug, 2000). The environmental part in this instrument comprises 188 items,

divided into four sub-sections: outdoor environment, entrances, indoor environment, and

communication. A total score is calculated, that is, a quantification of the degree of accessibility

problems in a particular case. The total score predicts the load caused by a particular combination

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of functional limitations and environmental design, thus giving a predictive measure of the degree

of accessibility problems. The analysis makes it clear that accessibility is a relative concept, since

problems only arise when environmental design is put in relation to an individual or group

population with functional limitations. This means that the total score is always 0 if the individual

or population has full functional capacity, whatever the design of the environment. To be able to

perform the assessment, one must have access to this manual, including rating forms, a rule, and the

handbook, (current edition comprising current Swedish accessibility norms, or corresponding

guidelines for the relevant country). Rating forms may be copied freely for one's own use or printed

from the files that are copied to the computer hard disk when the Housing Enabler 1.0 program is

installed. In addition, with the aid of the program one can print a short version of the rating forms.

Scores can be calculated manually, but access to a computer with the program Housing Enabler 1.0

is strongly recommended.

One important factor regarding the Housing Enabler is that the items are linked to current

Swedish building regulations, Swedish accessibility guidelines, and current legislation on housing

adaptation grants. It would be difficult to generalize this tool to use in the U.S. because of the

significant differences between housing environments. At this point there are few completed and

published studies to demonstrate the Enabler s reliability, validity or clinical utility in Sweden;

however, it is very important to reveal that there are several studies in progress related to the

Housing Enabler. An important part of the development of standardized methods of assessment and

analysis is the establishment of normal values for an environment. A study was carried out to test

inter-rater reliability. It was tested in practice by occupational therapists in primary health care.

After further revisions of "The Enabler" and pre-teaching of raters, each of 30 individuals in their

home environments was assessed by two independent raters. Reliability was evaluated using the

kappa statistic. After only a few lessons in advance, the raters were able to administer the

assessment in practice in a reliable way. Agreement between raters was very good to good, K =

0.68-0.87. The results showed that the instrument has high or very high reliability. Moreover,

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during the course of the study the definitions and instructions were successively clarified, which led

to improvements in the content validity of the instrument (Iwarsson & Isacsson 1996). According

to their study, the Housing Enabler assessment yielded an objective, professional, norm based, and

predictive result. This study may have many limitations such as variations between individuals

depending on age, gender, diagnosis and housing. A large number of empirical studies are needed

to establish normal values in Sweden. The Housing Enabler suggests that 0 should be regarded as

the normal value, since this is the total score in all cases where the individual does not show any of

the functional limitations assessed by the instrument. In order to capture subjective, user-oriented

data, another kind of instrument must be used. When using the Housing Enabler, the environmental

analysis requires a familiarity with assessing physical barriers in the built environment and up-to-

date knowledge of standards and functional demands from the point of view of accessibility. It is

difficult for persons outside the profession of occupational therapy to administer Step 1 in a reliable

and valid way, while Step 2 could be administered by architects, technicians or occupational

therapists. If different professions are involved, it is strongly encouraged to have close co-

operation, especially when it comes to data analysis. This assessment is available in book and

software form in both Swedish and English.

The Safety Assessment of Function and the Environment for Rehabilitation (SAFER)

The Safety Assessment of Function and the Environment for Rehabilitation (SAFER) has

been studied by Rosemary Oliver, who represented the Canadian Occupational Therapy Association

and Comprehensive Rehabilitation and Mental Health Services in Toronto, Ontario. The SAFER

Tool is an occupational therapy assessment of home safety and function for individuals who live in

their own homes. It is designed to identify and describe safety concerns of an individual in his or

her own home and to collect information to plan interventions and recommendations to improve

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safety. Theoretically, the instrument is grounded in the assumption that people s performance in

activities at home is a function of their skills and abilities interacting with their physical and social

environments (Lawton & Nehemow, 1973). It is not appropriate to look at the home environment

alone nor is it adequate to concentrate on a person s abilities alone. Both aspects are a vital part of

assessment of function and safety. Initially, the items for the SAFER Tool were generated for use

with a psycho-geriatric population. Later, with minor revisions, it was expanded to be appropriate

for use with clients with physical disabilities as well. The SAFER Tool measures 14 domains and

97 items. The domains are living situation, mobility, kitchen, fire hazards, eating, household,

dressing, grooming, bathroom, medication, communication, wandering, memory aids, and general

issues. It is primarily designed for the elderly with cognitive and or physical disabilities, but it can

be used for the assessment of other age groups and clinical problems. Reliability and validity of the

SAFER Tool were examined in two studies. The first study was undertaken in two steps (Letts &

Marshall, 1995; Letts, Marshall, & Cawley, 1995). First, an expert panel of clinicians and older

adults reviewed the content of the instrument. Panel members categorized each item of the

instrument and consensus was achieved. The meaning of each item was clarified. In the second

step, data were collected on 56 older adults referred for OT services in the community. In the

second study, data were collected on a sample of 38 people receiving OT services from five

participating sites in Ontario and British Columbia. Along with the SAFER Tool, measures of ADL

(Physical Self-Maintenance Scale), IADL (Instrumental Physical Self-Maintenance Scale, (Lawton

& Brody, 1969)) and (Standardized Mini-Mental State Examination, (Molloy, Alemayehu, &

Roberts, 1991)) were administered (Letts, Scott, Burtney, Marshall, & McKean, 1998). Internal

consistency was examined with data from the first study. The evaluation of internal consistency

examines whether or not the items included in the SAFER tool consistently measure the same basic

construct. The data were analyzed using Kuder-Richardson estimates. A coefficient of 0.70 was

considered acceptable, and the actual co-efficient was 0.83, well above the criteria giving the

SAFER Tool statistic internal consistency. Inter-rater reliability as well as test-retest reliability was

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tested to be very good. Content validity was examined and 97 items were established and it was

determined that the SAFER Tool was comprehensive in its coverage of items to examine a person s

ability to function safely in the home environment. Construct validity is tested when hypotheses

about the instrument were established and tested. Both of the studies examined construct validity

and validity has been supported in relation to cognitive impairment, which is certainly an important

hypothesis for clinicians in practice, however, further research is needed to examine the construct

validity of the SAFER Tool (SAFER 2001). The SAFER assessment is available in manual form.

The Canadian Occupational Performance Measure (COPM)

The Canadian Occupational Performance Measure (COPM) is an individualized measure designed

for use by occupational therapists to detect change in a client's self-perception of occupational

performance over time. This tool does not offer specific home modification recommendations. The

COPM is intended for use as an outcome measure, and as such, should be administered at the

beginning of occupational therapy services, and again at appropriate intervals thereafter, as

determined by the client and therapist.

The COPM is a standardized instrument, with specific instructions and methods for

administering and scoring the test. It is designed as an outcome measure, with a semi-structured

interview format and structured scoring method. Change scores between assessment and

reassessment using the COPM are the most meaningful scores derived from this tool. The COPM

has been used in over 35 countries in the world, and has been currently translated into more than 20

different languages. The test-retest reliability of the COPM is good to excellent, with intraclass

correlations coefficients of .63, .79 and .80 for performance score and .84, .75 and .89 for

satisfactions scores and the validity. Research indicates that change in overall functions as rated by

caregiver, clients, and therapists correlates significantly with change scores on the COPM (Law et

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al., 1998). In a review of the emerging research and clinical literature related to the COPM since

1994, the conclusion was that the COPM is a valid, reliable, clinically useful and responsive

outcome measure acceptable for occupational therapist practitioners and researchers (CAOT, 2004).

The test manual indicates that the COPM takes between 30 and 40 minutes to administer

(Law et al., 1998). It is easily accessible and economic to use. Information is recorded directly on

the form. Both a detailed manual and training video are available from the publishers. A majority of

clinicians report that it provides meaningful and useful information and that it helps frame practice

within a client-centered model. The semi-structured interview format is acceptable to both clients

and clinicians (Toomey, Nicholson & Carswell, 1995). The measure is flexible since allowances

and modifications can be made to address specific functional concerns. One concern with the

measure included the difficulty for some clients, particularly those early in the rehabilitation

process or those with limited insight, to identify occupational performance issues. The rating scale

has also been problematic with some clients and there can be a tendency not to use its full range

(Law et al., 1998). The information gained provides specific information regarding occupational

performance issues and indication of the client s perception of importance and satisfaction with

occupational performance as well as any change that has occurred (Toomey, Nicholson & Carswell,

1995).

The COPM information includes a video, workbook, manual and client forms. The training video

demonstrates how to administer and score the COPM with clients. The workbook is a self-

instructional program companion to the training video; the manual describes the history, features,

development, reliability & validity of the COPM. It includes instructions for test administration

and scoring, the process to follow, examples of using the COPM, and references. Individual forms

are used to record data for each client.

There are many assessment tools being used in the field of home modification and barrier-free

design. A standard protocol for home assessment has not yet been developed. A process that

encompasses both The Person-Environment-Occupation-Performance Model and utilizes a valid

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and reliable assessment tool resulting appropriate recommendations is not yet common practice in

the field of home modification and barrier-free design. There have been few research studies on

the topic of barrier-free design and there seems to be a lack of a common conceptual base with

which to guide the development and use of environmental assessments (Cooper, Cohen, Hasselkus

1991). Also, none of the assessments reviewed for this study provide detailed instruction on what

actions to take as a result of data collected from assessment. One assessment did offer suggestions

on what changes to make, adaptive aids to be used and even listed their vendor and price. That

assessment developed by Lifease®, Inc., is a software program. This assessment addresses the

home environment for the consumer but also offers appropriate suggestions from assistive

technology or home modifications to the appropriate products. This assessment, however, has not

yet been shown to possess both adequate clinical utility and psychometric properties.

Major occupational therapy texts and practice sources illustrate that environmental assessments

are viewed by the profession primarily as situation specific and centered on the home. Referential

texts; Willard and Spackman s Occupational Therapy (Hopkins & Smith, 2003), Christiansen and

Baum s Occupational Therapy (Christiansen & Baum, 2005) and Trombly and Radomski s

Occupational Therapy for Physical Dysfunction (Trombly & Radomski, 2002), address the need for

home modifications through barrier free design but provide only a brief overview for making these

changes.

The assessments reviewed are similar in price. The Housing Enabler is on the expensive side;

however, the software makes replication of the forms easy. The Housing Enabler does offer

assessment software. Neither the Canadian Occupational Performance Measure and the Safety

Assessment of Function and the Environment for Rehabilitation have software; however, they do

have a video available for purchase. The Housing Enabler did state that it is only valid and reliable

when an occupational therapist is performing the assessment. The environmental analysis requires

a familiarity with assessing physical barriers in the built environment and up-to-date knowledge of

- 16 -

standards and functional demands from the point of view of accessibility. Similarly the COPM and

the SAFER were tested with occupational therapists.

These assessments offer very little insight into how well their results may be utilized by others.

This begs the question as to how universal current home modification assessment tools are with

other persons involved in the assessment and modification process such as architects, contractors,

or even the clients themselves. Ongoing studies on co-variation between objective, norm-based

Housing Enabler analyses and results of users' subjective rating of accessibility problems will give

more knowledge about the validity. Even the authors of the Housing Enabler mention that this

assessment may only give crude predictive results, that there are some inconsistencies in the scoring

and that only after further studies are conducted will we be able to give recommendations as to the

accuracy with which rating results should be reported. All three assessments offer information

relating to performance, however, they do not offer much in the area of providing sound

recommendation.

Each of the assessment tools addressed in this document was developed outside of the United

States. Current research involving these assessment tools are being conducted over-seas. However,

there has been no indication that they will address current U.S. housing and population trends.

Until more outcome studies are done to research the effectiveness of current home modification

assessment tools, occupational therapists in the U.S. are limited to utilizing tools that do not possess

tested validity, reliability or clinical utility.

The Effectiveness of Occupational Therapy for Home Modification Recommendation

Few outcome studies have been conducted to demonstrate the effectiveness of occupational

therapists recommendations for home modification. This is disturbing considering that according

to the Standards of Practice for Occupational Therapy, Standard 1: Professional Standing and

Responsibility 10, a registered occupational therapist is knowledgeable about research in the

- 17 -

practitioner's areas of practice. A registered occupational therapist applies timely research findings

ethically and appropriately to evaluation and intervention processes (AOTA, 2004).

The study, Adherence to Occupational Therapist Recommendations for Home Modifications

for Falls Prevention, would be an exception (Cumming et al., 2001). This study examined

adherence to home modification recommendations made by an occupational therapist and attempted

to identify predictors of adherence. This outcome study included 178 persons whose mean age

equaled 74.6 years old. Those persons were visited by an occupational therapist for an evaluation

and recommendations for appropriate home modifications for falls prevention. One year later, a

research assistant visited these persons homes to assess adherence. The outcomes of this study

yielded 52% of the recommendations were fully or partially adhered to. The study concluded that a

major barrier to adherence to home modification recommendations is that many older people do not

believe that home modifications will reduce their risk of falling. In older people, falls are

associated with significant mortality and morbidity and frequently lead to a decline in physical

and/or psychological function, ultimately encroaching on independence and autonomy. Given that

most falls result from a dynamic interaction between intrinsic and extrinsic factors, a

multidisciplinary approach to their management incorporating medical, functional, and

environmental assessment is likely to be most effective. To date, there is limited evidence to

support a population-based preventive strategy. It has become imperative to focus on high-risk

groups with the potential to benefit. There is increasing evidence to support intervention in specific

populations. The role of the occupational therapist and home environment modification has not

been concretely established. However, a study has shown a reduction in falls in patients having a

home environment assessment by an occupational therapist on discharge from a hospital (Cumming

et al., 1999).

According to a study from the University of Buffalo s occupational therapy department,

supplying the frail elderly with needed low-tech assistive devices and home modifications reduced

health care spending on average by $17,437 per person. Those in the control group, who were

- 18 -

supplied with the usual care including nursing home, at-home health care and services provided by

community agencies, averaged a health care cost of $31, 610 per individual during the 18 moth

study period. This cost was compared to $14, 173, costs for the intervention group that received the

low tech devices and home modifications (Mann, Ottenbacher, Fraas, Tomita, Granger, 1999).

Most of the savings resulted from reduced institutional care costs , including shorter hospital stays.

Persons who received assistive devices and home modifications also had fewer falls, indicating that

prevention of injuries was also a factor.

According to The Standards of Practice for Occupational Therapy, a registered occupational

therapist should systematically assess the efficiency and effectiveness of occupational therapy

services and design and implement processes to support quality service delivery (AOTA, 2004). In

spite of this expectation few outcome studies have been conducted to demonstrate the effectiveness

of occupational therapists recommendations for home modification. If occupational therapists are

going to respond to the need for performing home safety evaluations, we need efficacy outcome

studies to support this practice and convince our patients, the referring physicians, legislators and

the payers that our services are in fact beneficial.

Legislature

In order to best serve our clients, occupational therapists must understand current legislature

relating to home modification and barrier free design. According to The Occupational Therapy

Standards of Practice, an occupational therapy practitioner maintains current knowledge of

legislative, political, social, cultural, and reimbursement issues that affect clients and the practice of

occupational therapy (AOTA, 2004). Also, in relation, The Occupational Therapy Code of Ethics

states that OT s shall critically examine and keep current with emerging knowledge relevant to their

practice so they may perform their duties on the basis of accurate information (AOTA, 1998).

Occupational therapists should possess a basic awareness of such legislature since laws dictate

standards, dimensions and characteristics for many of our recommendations relating to home

- 19 -

modification and barrier free design. It is important for occupational therapists working in the field

of home modification and barrier free design to be aware of the laws and regulations that apply to

their clients at a city, state and federal level.

Americans With Disabilities Act of 1990

The Study Empowerment Through Occupational Therapy: The Americans With Disabilities

Act Title III deals with such issues as occupation therapist s knowledge (Redick, McClain, Brown,

2000). The study randomly sampled 510 occupational therapists with 229 responding. Of those

surveys returned, 159 respondents who serve clients who use wheelchairs met inclusion criteria.

The purpose of this study was to determine whether occupational therapists (a) value a role

educating consumers about the Americans With Disabilities Act of 1990 (ADA; Public Law 101-

336); (b) are knowledgeable regarding Title III of the ADA; and (c) implement provisions and

empower consumers who use wheelchairs to access public accommodations. The conclusion of this

study revealed that therapists lack of knowledge and their self-reported inaction with regard to

ADA Title III may affect the accessibility of the environment, independence, and empowerment of

clients who are wheelchair mobile and, therefore, may impede progress toward fully inclusive

communities (Redick, McClain, & Brown, 2000).

Knowledge about the Americans With Disabilities Act of 1990 should not be our only

concern as therapists Other current legislature relating to home modification and barrier free

design that occupational therapists should possess are a basic awareness of The Fair Housing Act,

Section 504 of the Rehabilitation Act of 1973, state Medicaid Waiver Programs and No-Fault Laws,

and The Architectural Barriers Act of 1968. Laws dictate standard dimensions and characteristics

for such features as door widths, clear space for wheelchair mobility, audible and visual signals,

grab bars, switch and outlet height, and more. There are requirements found in state, local and

model building codes. The accessibility standards of the Americans with Disabilities Act (ADA)

regulate the accessibility of public buildings and facilities. Even though the ADA is limited to

- 20 -

public areas, the adoption of this act into the constitution symbolizes a great achievement for

accessibility for all. Also if there are changes in legislature in the future at a federal level to include

private dwellings the ADA may be used as a building block for those changes. Most states or

localities in this country have adopted building codes to govern construction within their

jurisdictions. These building codes are enforced by local or state code officials. The Civil Rights

Division believes that incorporation of the design and construction requirements of the Fair

Housing Act and the Americans with Disabilities Act into building codes represents an opportunity

to enhance compliance with these federal laws. Some model codes and some state and local codes

include provisions that may afford an even greater degree of accessibility in some respects than

does federal law. There are many other important legislatures that involve home modification and

barrier free design. Appendix C will include internet links to relevant information regarding home

modification legislature and reference material.

Medicaid

The Medicaid Program is responsible for the implementation and ongoing administration of

home and community-based services, waivers and targeted case management programs for special

population groups. The Medicaid Program studies, plans, and implements services relating to the

needs of special populations such as the elderly, the mentally ill, and the physically and mentally

disabled. Under Section 1915(c) of the Social Security Act, Medicaid law authorizes the Secretary

of the U.S. Department of Health and Human Services to waive certain Medicaid statutory

requirements. These waivers enable States to cover a broad array of home and community-based

services (HCBS) for targeted populations as an alternative to institutionalization. Waiver services

may be optional State Plan services which either are not covered by a particular State or which

enhance the State s coverage. Waivers may also include services not covered through the State

Plan such as respite care, environmental modifications, or family training.

- 21 -

To be a waiver participant, an individual must be medically qualified, certified for the

waiver s institutional level of care, choose to enroll in the waiver as an alternative to

institutionalization, cost Medicaid no more in the community under the waiver than he or she would

have cost Medicaid in an institution, and be financially eligible based on their income and assets. If

one chooses to enroll in the waiver as an alternative to institutionalization it is imperative that this

person be as independent as possible. Modifications to a persons dwelling may increase the

independence level of a waiver participant thus lowering their cost to remain in the community.

No-Fault Law

One of the largest single expenses incurred in catastrophic injury cases is that of provision

of home modification and barrier free accommodations. The no-fault law provides little guidance to

claimants and insurers as to the determination of how much will be paid. According to Section

3107(1)(a) of the Michigan No-Fault Act, personal protection benefits are payable for all reasonable

charges incurred for reasonably necessary products, services and accommodations for an injured

person's care, recovery or rehabilitation (2005). The law's general mandate that all, "reasonable

charges" be paid leaves room for much flexibility in resolving such claims. Modifications can range

from simple placement of handrails in the bath tub, to the building of an entirely new home.

Insurers may wish to place limits on the ability of the claimant to sell the home for profit or to make

subsequent claims for further accommodations. Where dramatic modifications are called for, the

claimant should first consult with an occupational therapist to determine what should be done, and

indeed, whether modification is reasonable. An architect may be required to translate the therapists'

recommendations into a solid plan. A contractor may then bid on the architect s plan. An important

aspect of these claims is the lengthy delays that often attend their resolution. This is because home

modification claims are usually the largest single claim beyond the acute hospital stay. Insurers may

be reluctant to pay in the absence of an agreement specifying terms and limitations; claimants

usually do not have the means to purchase these modifications in the absence of insurer assistance.

- 22 -

Claimants should be aware of their right to a "declaratory" ruling, in advance of incurring any

expense on home modifications. The unpublished cases of Mase v. Auto-Owners (1992) and

Proudfoot v State Farm Mutual Insurance Company (2003) are helpful in this regard.

During our research for this project it was noted that many contributions to the field of home

modification and barrier free design were of foreign origin. For example all of our assessment tools

discussed were developed in other countries. It should also be noted that there are different

legislature governing the use of home modification and barrier free design in countries around the

world. It is important to realize what trends are occurring in other countries so that we may better

practices in the United States.

Lifetime Homes Concept

In 1991 the Lifetime Homes concept was developed in the United Kingdom. In the mid

1990s the Government indicated its wish to extend Part M of the building regulations, which deals

with accessibility in public buildings, to cover houses as well. New regulations came into force for

all housing built after October, 1999 (Joseph Rowntree Foundation, 2005). Following government

approval of the London Plan in February 2004, Lifetime Homes are now mandatory across London

and it is anticipated that the rest of England will follow suit when the Regional Spatial Strategies

are drawn up (Lifetime Homes, 2005). Lifetime Homes have sixteen design features that ensure a

new house or flat will meet the needs of most households. For example, all new homes must have

level front entrances for the benefit of disabled or elderly people (Lifetime Homes, 2005). This

simple design adjustment would make many U.S. homes, where traditionally steps are standard,

more accessible. The focus is on accessibility and design features that make the home flexible

enough to meet whatever comes along in life.

A research report suggests that not only will the occupiers of homes benefit from Lifetime

Homes, but so too will tax payers. Savings will come from reduced expenditure on adaptations and

- 23 -

reduced need to move people to residential care, saving in health care and re-housing costs. When

designing new homes it is now necessary to take account of three sets of requirements: The first is

Part M of the Building Regulations that has been extended to include all new homes. The second is

the Housing Corporation s Scheme Development Standards, which all housing funded with

Housing Corporation money must meet. The third is Lifetime Home standards, which many

commissioning clients and local authorities now require. The figure below (See Figure 1) provides

an illustrated example on meeting Lifetime Homes 16 design standards (Joseph Rowntree

Foundation, 2005).

Figure 1. Lifetime Homes 16 Design Standards

From Building Lifetime Homes Foundations, published in 1997 by the Joseph Rowntree Foundation. Reproduced by permission of the Joseph Rowntree Foundation. (c) Edwin Trotter Associates.

- 24 -

Designing new homes to the Lifetime Homes standards makes sense. They include a number

of differentiating features. Lifetime Homes are providing those who live in them with many

advantages, and are giving private builders a marketing edge in relation to the second-hand housing

stock. Lifetime Homes will be suitable for the increasing older population, the vast majority of

disabled people, as well as the non-disabled person. This will insure a wider market of potential

buyers and residents, probably increasing the value and the ease with which the house can be re-

sold.

Recognition of the positive effects of homes of flexible design and adaptability on longevity

of tenure and community sustainability is apparent. Lifetime Homes is the accepted standard across

the UK ensuring that everyone will eventually be given the choice of living in a Lifetime Home

(Lifetime Homes, 2005).

As we look at current trends on the current occupational therapist practice in the field of

home modification and barrier free-design, it is important for the occupational therapist that is

performing a home assessment to understand current legislature relating to home modification and

barrier free design. In order to advance in the field of home modification and barrier free design,

occupational therapists should possess an awareness of related legislation as well as what trends are

taking place throughout the world.

Research Question

A literature review was conducted to identify the current literature in the field of home

modification and barrier free design in both the U.S. as well as the U.K. This study was conducted

to answer the research question, What is the current practice of occupational therapists in the

United States?

- 25 -

CHAPTER III

METHODOLOGY

Introduction

There exists a relationship between the occupational therapy profession and the field of

home modification and barrier free design. By the year 2020, approximately one in six Americans

will be elderly (Johansson, 2003). Many of these aging adults will not have safe and accessible

home environments. It is often possible to adapt or modify current and existing housing using

various assistive technologies. The AARP reported in May 2000 that the desire to remain in ones

current residence for as long as possible becomes more prevalent as age increases. Seventy-five

percent of those age 45 to 54, and 83 percent of those age 55 to 64 strongly or somewhat agree that

they wish to remain in their homes as long as possible, while 92 percent of those age 65 to 74 and

nearly all of those age 75 and over (95 percent) want to do so (AARP 2000). Occupational

therapists may be called upon to assess the functional fit of housing for clients of any age with

disabilities. This study will explore what current trends are taking place in the field of home

modification and barrier free design and to examine how occupational therapists view their role in

the practice of home modification and barrier-free design.

Review of the Research Question

The study was designed to improve our understanding on the current occupational therapist practice

in the field of home modification and barrier free design in the U.S. Occupational therapists are

involved in the field of home modification and barrier free design. However, there appears to be a

- 26 -

lack of outcome studies and continuing education workshops needed to be ensuring quality

outcomes and to ensure the reliability and validity of current assessment tools.

The research questions included in our survey were developed based on theoretical

discussions about what may be pertinent in the area of home modification and barrier free design.

Sample Demographics

All participants of this study were United States occupational therapists and members of the

American Occupational Therapy Association. Two hundred fifty occupational therapists were

randomly selected to be invited to participate in this study from the AOTA membership listing.

One hundred twenty one occupational therapists returned the survey. The American Occupational

Therapy Association (AOTA) is the nationally recognized professional association of more than

35,000 occupational therapists, occupational therapy assistants, and students of occupational

therapy. These practitioners serve people with physical illnesses and injuries, congenital and

chronic conditions, and mental and developmental disabilities, helping them to regain, develop, and

build skills essential to restoring or maintaining independent function, health and well-being, and

social participation (AOTA, 2005). Occupational therapists held about 82,000 jobs in 2002, (U.S.

Department of Labor).

Survey Instrument

A 16-question survey was developed for the study (Appendix A). Surveys were mailed out

on July 1, 2003 and were collected on July 29th, 2003 to be included in the study. A cover letter

introduced the survey, explaining the voluntary nature of the study (See Appendix E). Participants

were asked not to put their names anywhere on the survey. The survey contains questions, which

include some personal demographic items and takes approximately 10 minutes to complete. If the

- 27 -

participants chose not to participate, they were asked to return the survey in the envelope provided.

Participants were informed that returning a completed survey indicated their consent for use of their

responses. Completing this survey was voluntary and anonymous. The study was approved by the

HSIRB at Western Michigan University, USA.

Data Collection and Analysis

Our survey was created and has been analyzed for descriptive statistics. Data was collected

from direct mailing from a random sample of occupational therapists. The survey questions are

composed of 14 forced choice and two open ended questions. Participants were asked to respond to

each question by circling the appropriate number or response. Questions 1-11 and 13-15 were either

multiple choice, fill in the blank, or selecting a choice on a Likert scale from. All survey responses

that are nominal were tallied on a data collection sheet (See Appendix D). Descriptive statistics

were further analyzed using Microsoft Excel. Questions 12 and 16 are open ended questions.

Question 16 asked participants for their opinion of what they felt is the role of occupational therapy

was in the emerging practice of home modification and barrier free design. Current training

methods were considered, and possible correlations between therapist s views on what the role of

Occupational therapy in home modification and barrier free design were examined; themes from the

open-ended question 16 were documented. Quantitative data from the returned surveys were coded

and entered into a Microsoft Excel spreadsheet. Open-ended data was analyzed for themes.

- 28 -

CHAPTER IV

FINDINGS

Survey Results

This survey revealed 121 responses equaling a return rate of 48%. Of the 121 occupational

therapists that responded 66% had achieved a bachelor s degree and 55% had reached a masters

degree level of education. Most of the respondents (47%) had been practicing between 16-30 years

followed by those who have been practicing between 1-5 years (39%). Most respondents were

currently working with pediatric clients 55%, geriatric clients 44%, and with adults 42%. Those

therapists completing this study were working in a wide variety of settings with many working in

several settings at once (See Figure 2).

Figure 2. Setting of Practice

Setting of Practice

19% 2

11%

316%

410%

512%

611%

74%

827%

1

2

3

4

5

6

7

8

Acute Care

Inpatient

Outpatient

Skilled Nursing

Home Health

Private Practice

Workplace

Other

- 29 -

Therapists were asked if they are ever involved with home accessibility considerations with

their clients. Of those 121 therapists that responded 35% answered no and 65% answered yes to

being involved with home accessibility considerations with their clients. Therapists were asked

what training had they received in the area of home modification and barrier free-design.

Respondents could have selected multiple ways in which they had received training; the two most

common areas in which they answered were self taught 60% and college course 41%. Less than

30% responded that they had received training from a seminar or workshop. Sixty four percent of

respondents also answered yes to training being offered in the area of home modification and

barrier free design as part of their entry-level curricula, with 36% answering that education was not

offered in that area of practice. Of those who responded yes to training being offered in the area of

home modification and barrier free design as part of their curricula, only 25% felt satisfied or very

satisfied as to how well they felt prepared for practice in this area. A majority of the respondents

answered neutrally (30%) and 13% felt dissatisfied or very dissatisfied as to how well they felt

prepared for practice in the area of home modification and barrier free design (See Figure 3).

Figure 3. Prepared for Practice

Prepared for Practice

14% 2

15%

343%

433%

55% 1

2

3

4

5

Very Dissatisfied

Dissatisfied

Neutral

Satisfied

Very Satisfied

- 30 -

Therapists were then asked to rate how satisfied they were with their current knowledge of

home modification and barrier free-design (See Figure 4). Almost half (49%) of the respondents

answered neutrally to this question, with an almost equal amount answering satisfied/very satisfied

(29%) as those who answered dissatisfied/very dissatisfied (22%).

Figure 4. Satisfaction with Current Knowledge

Satisfaction with current knowledge

2 19%

1 3%

53%

4 26%

3 49%

1 Count

2 Count

3 Count

4 Count

5 Count

Very Dissatisfied

Dissatisfied

Neutral

Satisfied

Very Satisfied

This survey found only two assessment tools currently being used by occupational therapists in

the area of home modification that have published studies revealing both adequate clinical utility

and psychometric properties. Those two assessments were the SAFER and the COPM. The

SAFER was listed to have been used by only two therapists who responded to this survey and the

COPM was listed once. Twenty-nine percent of those who responded to question 11 answered

yes to having administered home assessments that encompass home modification and barrier free

design solutions within the past year, and 71% that responded that they had not. Those therapists

responding to this survey were then instructed to skip to the final question if they had answered

no to having administered home assessments that encompass home modification and barrier-free

design solutions within the past year. Of the 29% of respondents that answered yes to

administered home assessments that encompass home modification and barrier free design solutions

- 31 -

within the past year, the majority (14%) answered to having performed 1-5 assessments per year

(See Table 1).

Table 1. Number of Assessments Performed Per Year

Number of Assessments performed per

year

Respondent

s

Percentag

e

1 through 5 17

14%

6 through 15 11

9%

16 through 30 2

2%

31 and over 5

4%

Of those respondents who responded yes to having administered home assessments that

encompass home modification and barrier free design solutions within the past year, over 97%

responded no to having been involved with any outcome studies or follow-up studies assuring

proper implementation and follow through with recommendations for home modification and

barrier-free design with less than 1% responded yes . Question 16 asked participants for their

opinion of what they felt the role of occupational therapy was in the emerging practice of home

modification and barrier-free design. Common themes were established from responses given.

There were 103 participants who responded to question 16 out of the 121 total who responded to

the survey, equaling an 85% response rate. The three common themes that were derived from

question 16 are that occupational therapy plays an important role in the emerging practice of home

modification and barrier free design, (51% of responses); continuing education is important, (14%

of responses) and that communication with the patient as well as other professions is imperative,

(72% of responses).

- 32 -

Discussion of Findings

We found that many occupational therapists are involved with home accessibility

considerations with their clients. However, there are limits to the representativeness of our sample

because of the 48% return rate. This may be because those therapists who are not currently

working in the area of home modification and barrier-free design may not have chosen to partake in

this study. It was deducted from the survey that many therapists did receive training in the area of

home modification and barrier-free design as part of entry-level occupational therapy curricula.

However, of those who responded yes to training being offered in the area of home modification

and barrier free design as part of their curricula, only 37% felt satisfied or very satisfied as to how

well they felt prepared for practice in this area. A majority of the respondents answered neutrally

(44%) and 19% felt dissatisfied or very dissatisfied as to how well they felt prepared for practice in

the area of home modification and barrier-free design. We felt this to be an indication that training

in the area of home modification and barrier-free design is being covered by the majority of

curricula. However, with occupational therapy covering a large spectrum of settings and

populations, curriculums may have offered those therapists only an introduction to this area of

practice as students. It was discovered from the survey results that therapists when asked to rate

how satisfied they are with their current knowledge of home modification and barrier-free design,

an almost equal amount answered satisfied/very satisfied as those who answered dissatisfied/very

dissatisfied and nearly half of the respondents answered neutrally to this question. This resulted in

an almost bell-shaped curve response. We believe that this may in fact support what was stated

previous that many therapists are receiving a basic knowledge of home modification and barrier-

free design in their educational curricula, but 75% feel they need more information. This would

then indicate the need for continued education for therapists. However, when therapists were asked

what training they have they received in the area of home modification and barrier-free design,

most responded they had received training through self teaching (60%), and fewer than half

- 33 -

responded having received training through a college course (41%). This is counter to the response

that (64%) of respondents answered yes to training being offered in the area of home modification

and barrier-free design as part of their entry-level curricula, with only 36% answering that

education was not offered in that area of practice. Another notable finding is that less than 21%

responded that they had received training from a seminar or workshop and that the majority (42%)

of those who responded answered that they had been self taught.

Twenty-nine percent of therapists responded that they have administered home assessments

that encompass home modification and barrier-free design solutions within the past year and 71%

that responded that they had not. At first glance that one might think that with such a low

percentage of occupational therapists administering home assessments there may not be much

interest in the practice. However, considering this survey was comprised of randomly selected

occupational therapists from throughout the US who are practicing in many different and unique

settings it is quite revealing that approximately 29% are performing home assessments that

encompass home modification and barrier-free design solutions. With almost a third of all

occupational therapists involved in the practice of home modification and barrier-free design, it is

concerning to see the lack of a standardized protocol for evaluation and recommendation in this

area of practice. Therapists recommendations may be questioned in a court of law,

recommendations derived from which ever assessment tool was used during evaluation. Over half

of those who responded to how satisfied they were with their assessment tool from the survey

reported that they had used an assessment tool of their own making, and over half of those

respondents were either satisfied or very satisfied with their assessment. Interestingly, of those who

responded to whether or not their home assessment tool provides adequate data that communicates

effectively across disciplines (i.e. doctors, architects, builders, clients) to provide justification for

implementation and for funding of home modifications, approximately 62% stated either no or

that they did not know, leaving an important process unattended. In order to make sound

recommendations an occupational therapist must have an assessment tool that will allow the

- 34 -

therapist communicate effectively across disciplines. There need to be more educational

opportunities for therapists working in the area of home modification and barrier-free design. With

more education there will be a better understanding of assessment and recommendation

implementation. Of those respondents who responded yes to administered home assessments that

encompass home modification and barrier-free design solutions within the past year over 97%

responded no to having been involved with any outcome studies or follow up studies assuring

proper implementation and follow through with recommendations for home modification and

barrier free design with less than 1% responded yes . In a time where the trend is shifting towards

evidence-based practice, more research and development is needed to create a valid and reliable

home modification assessment tool that offers good clinical utility and offers justifiable

recommendations that are easily translated among coordinating disciplines.

- 35 -

CHAPTER V

DISCUSSION AND SUMMARY

Limitations of the Study

More research is needed to improve our understanding on the current occupational therapist

practice in the field of home modification and barrier-free design. There are limits to

representativeness of our study. This studies sample size consisted of 121 occupational therapists

located in the United States. Future study response rate may benefit from reformulated and

structured questions. There are no previous surveys examining the field of home modification and

barrier-free design using data from occupational therapists throughout the United States. Therefore,

the survey questions made for this study are based on theoretical discussions about what may be

pertinent in the area of home modification and barrier free-design.

Conclusions and Recommendations

The role of occupational therapy in the emerging practice of home modification and barrier-

free design is regarded as important by occupational therapists in the United States. The absence of

a standard protocol, psychometrically sound assessments, and outcome studies demonstrating the

effectiveness of occupational therapy recommendations is disconcerting in a time of evidence-based

practice. Many occupational therapists are involved with home accessibility considerations with

their clients, however, less than a third responding to the survey report being very satisfied or

satisfied with their current knowledge of home modification and barrier-free design. It is important

to realize what trends are occurring in other countries so that we may better our own practices. In

the area of home modification and barrier-free design the assessment tools with researched

- 36 -

psychometric value were developed in countries other than the United States. It should also be

noted that there is different legislation governing home modification and barrier-free design in

countries around the world. More workshops should be made available for continuing education.

Also, more outcome studies need to be performed to ensure quality outcomes and to ensure the

reliability and validity of current assessment tools. This is not only important for the relevancy

occupational therapy in the field of home modification and barrier-free design but for following our

code of ethics and our standard of practice.

Summary

The implementation of this study has answered some of the questions while also paving the

way for additional research to bring more clarification of current occupational therapy practice in

the field of home modification and barrier-free design. The most important findings of this study

indicate that the need for reliable and valid assessment tools is imperative, and that there should be

greater access to continued education on home modification and barrier-free design.

- 37 -

APPENDIX A

Survey Instrument

Survey Of Current Occupational Therapist Practice In The Emerging Field Of Home Modification And Barrier Free Design

Directions:

PLEASE READ BEFORE STARTING

Please respond to each question by either circling the appropriate number or response or by filling in

the blank to the best of your knowledge. Your candid response to the items will enhance the validity of this

research. To maintain your anonymity do not put your name on this questionnaire. Once you have

completed the questionnaire please return it by placing the completed forms inside the self addressed,

postage free envelope provided. If you choose not to participate, please return the questionnaire in envelope

provided. Returning the completed survey indicates your consent for use of the answers you supply.

1. What credentials have you achieved? (Circle all that apply) a. Licensed OTR/OT b. Bachelors Degree c. Masters Degree d. Licensed Building Contractor (In your state)

2. How many years have you been in practice as an OT/OTR? (Circle all that apply) a. 1-5 b. 6-15 c. 16-30 d. 31 and over

3. In what area of OT are you currently working? (Circle all that apply) a. Geriatrics b. Pediatrics c. Mental-Health d. Adolescents e. Adults f. Other

4. In what setting are you currently working? (Circle all that apply)

a. Acute Care b. Inpatient c. Outpatient d. Skilled Nursing Facility e. Home health f. Private Practice g. Workplace (i.e. work hardening) h. Other

5. Are you ever involved with home accessibility considerations with your clients? (Circle one) a. No b. Yes

6. What training have you received in the area of home modification and barrier free design? (Circle all that apply) a. Self taught b. Apprenticeship/Technical School c. Seminar/Workshop d. College Course

- 38 -

7. Was training offered in the area of home modification and barrier free design as part of your entry level occupational therapy curricula? (Circle one) a. No b. Yes

8. If training was offered in the area of home modification and barrier free design as part of your occupational therapy curricula, how well do you feel it prepared you for practice? (Circle one) 5 =Very Satisfied; 4 =Satisfied; 3 =Neutral; 2 =Dissatisfied; 1 =Very Dissatisfied

9. How satisfied are you with your current knowledge of home modification and barrier free design? (Circle one) 5 =Very Satisfied; 4 =Satisfied; 3 =Neutral; 2 =Dissatisfied; 1 =Very Dissatisfied

10. Have you administered home assessments that encompass home modification and barrier free design solutions within the past year? (Circle one) a. No b. Yes

If you answered no for question 10 please skip the following questions (11-16) and answer the last question, number 16 of the survey. If you circled yes for question 10 please continue to answer (11-16):

11. How many home assessments do you perform per year? (Fill in the blank) a. 1-5 b. 6-15 c. 16-30 d. 31 and over

12. What home assessment tool or tools have you used within the past year? (Fill in the blank)

_______________________________________________________________

13. How satisfied are you with your current assessment tool? (Circle one) 5 =Very Satisfied; 4 =Satisfied; 3 =Neutral; 2 =Dissatisfied; 1 =Very Dissatisfied

14. Does your home assessment tool provide adequate data that communicates effectively across disciplines (i.e. Drs, Architects, Builders, Clients) to provide justification for implementation and for funding of home modifications? (Circle one) a. No b. Yes c. Unknown

15. Have you been involved with any outcome studies or follow up studies assuring proper implementation and follow through with recommendations for home modification and barrier free design? (Circle one) a. No b. Yes

All occupational therapists completing this survey please complete the following question:

16. What do you feel is the role of Occupational Therapy in the emerging practice of home modification and barrier free design?

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Appendix B

Assessment Tools Reviewed

Assessment Tool Author/Source

CMHC Maintaining Seniors Independence, 1989

Housing Survey ARO Evaluation, 1988

Housing Enabler Iwarrsson & Isacsson, 1999

Housing Assessment UCP

UFAS Checklist U.S. Access Board, 1990

Client Assessment Form John Salman

Home Assessment Checklist Center for Universal Design

Easy Access Housing For Easier Living Easter Seals and Century 21

CASPAR EHLS

The Accessibility Checklist Goltsman, 1992

COPM Law, 1994

Environmental Competence Questionnaire CMHC, 1982

Environmental Grid Description Assess Dunning, 1972

Environment Preference Questionnaire Kaplan, 1977

POE Cooper, Ahrentzen, & Hasselkus, 1991

Home Modification Workbook Adaptive Environments Center, 1988

Modification Checklist CMHC, 1988

Person-Environment Fit Kahana, 1974

Person-Environment Fit Scale Coulton, 1979

SAFER COTA, 1991

Source Book Kelly & Snell, 1989

EASE3 Lifease, 1998

Enviro-FIM Steinfeld & Danford, 1997

Home Mod Workbook Adaptive Environments Ctr, 1988

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HOME Inventory Caldwell & Bradley, 1984

Physical Architectural Features Checklist Moos & Lemke, 1996

Westmead Home Safety Assess (WeHSA) Clemson, 1997

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Appendix C

Web Resources

http://www.access-board.gov/adaag/html/adaag.htm

http://www.jrf.org.uk/housingandcare/lifetimehomes/

http://www.aota.org/index.asp

http://www.odpm.gov.uk/stellent/groups/odpm_buildreg/documents/page/odpm_breg_025494.hcsp

http://www.aotf.org/cgibin/sbcgi.cgi/database/assess?dbid=asses&lng=0&dplc=0&strt=1&bspi=/database/assess&eud=&stxt=&sidx=1&styp=6&nhit=100&sdisp=s

http://www.cms.hhs.gov/

http://www.disability.gov.uk/

http://www.enableage.arb.lu.se/index.html

http://www.usdoj.gov/crt/housing/housing_coverage.htm

http://www.jrf.org.uk/links/

http://www.hud.gov/offices/fheo/disabilities/sect504.cfm

http://www.hunter-jones.freeserve.co.uk/bregs.htm

http://www.dhmh.state.md.us/mma/waiverprograms/

https://www.caot.ca/ebusiness/source/orders/index.cfm?ETask=1&Task=1&SEARCH_TYPE=FIND&FindIn=0&FindSpec=COPM

http://www.lifetimehomes.org.uk/home_front.php

http://www.housing.wales.gov.uk/index.asp?task=content&a=w22&b=&lc=E

http://www.ex.ac.uk/Affiliate/stloyes/ugradres/otasses.htm

http://www.arthritis.org/resources/Home_Life/design.asp

http://www.homemods.org/

http://www.usc.edu/dept/gero/nrcshhm/index.htm

http://www.universaldesignonline.com/pages/764806/index.htm

http://www.aarp.org/life/homedesign/

http://www.katsnet.org/fact7.html

http://www.enabler.nu/projekt.html

http://www.caot.ca/copm/

http://www.uthscsa.edu/sah/assistive_tech/webliography.htm

http://www.iccsafe.org/

http://www.abledata.com/

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Appendix D

Survey Data Collection Set

Survey Question & Answers

Frequency

1. What credentials have you achieved? a. Licensed OTR/OT ___121___ b. Bachelors Degree ___66____ c. Masters Degree ___55____ d. Licensed Building Contractor (In your state) ___1_____

2. How many years have you been in practice as an OT/OTR? a. 1-5 ___39____ b. 6-15 ___23____ c. 16-30 ___47____ c. 31 and over ___11____

3. In what area of OT are you currently working? a. Geriatrics ___44____ b. Pediatrics ___55____ c. Mental-Health ___9_____ d. Adolescents ___14____ e. Adults ___42____ f. Other ___24____

4. In what setting are you currently working? a. Acute Care ___17____ b. Inpatient ___22____ c. Outpatient ___30____ d. Skilled Nursing Facility ___19____ e. Home health ___24____ f. Private Practice ___22____ g. Workplace (i.e. work hardening) ___7_____

h. Other ___52____

5. Are you ever involved with home accessibility considerations with your clients? a. No ___42____ b. Yes ___77____

6. What training have you received in the area of home modification and barrier free design? a. Self taught ___72____ b. Apprenticeship/Technical School ___1_____ c. Seminar/Workshop ___36____ d. College Course ___62____

7. Was training offered in the area of home modification and barrier free design as part of your entry-level occupational therapy curricula?

a. No ___43____ b. Yes ___75____

8. If training was offered in the area of home modification and barrier free design as part of your occupational therapy curricula, how well do you feel it prepared you for practice?

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5 =Very Satisfied ___4_____ 4 =Satisfied ___26____ 3 =Neutral ___35____ 2 =Dissatisfied ___12____ 1 =Very Dissatisfied ___3_____

9. How satisfied are you with your current knowledge of home modification and barrier free design? 5 =Very Satisfied ___4_____ 4 =Satisfied ___31____ 3 =Neutral ___56____ 2 =Dissatisfied ___22____ 1 =Very Dissatisfied ___4_____

10. Have you administered home assessments that encompass home modification and barrier free design solutions within the past year?

a. No ___84____ b. Yes ___35____

11. How many home assessments do you perform per year? a. 1-5 ___17____ b. 6-15 ___11____ c. 16-30 ___2_____ d. 31 and over ___5_____

11. What home assessment tool or tools have you used within the past year?

a. SAFER 2 b. COPM 1 c. other assessment tool 33

13. How satisfied are you with your current assessment tool? 5 =Very Satisfied ___4_____ 4 =Satisfied ___14____ 3 =Neutral ___12____ 2 =Dissatisfied ___3_____ 1 =Very Dissatisfied ___0_____

14. Does your home assessment tool provide adequate data that communicates effectively across disciplines (i.e. Drs, Architects, Builders, Clients) to provide justification for implementation and for funding of home modifications?

a. No ___10____ b. Yes ___13____ c. Unknown ___11____

15. Have you been involved with any outcome studies or follow up studies assuring proper implementation and follow through with recommendations for home modification and barrier free design?

a. No ___34____ b. Yes ___1_____

16. What do you feel is the role of Occupational Therapy in the emerging practice of home modification and barrier free design?

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APPENDIX E

Cover Letter

May 2003

Dear Occupational Therapist,

My name is Christian Petrovich. I am a masters of occupational therapy student at Western Michigan University in Kalamazoo, Michigan. I am conducting a study entitled, Survey Of Current Occupational Therapist Practice In The Emerging Field Of Home Modification And Barrier Free Design, with Dr. Debra Lindstrom Hazel from Western Michigan University's Department of Occupational Therapy for my masters thesis. The purpose of this study is to ascertain what current trends are taking place in the field of home modification and barrier free design and to examine how occupational therapists view their role in the practice of home modification and barrier free design. These trends may lead to further study and research which may in turn help to refine the role of occupational therapists in the emerging practice of home modification and barrier free design to better meet our clients needs.

I am writing this letter to invite you to participate in this project. A survey is enclosed. Returning the completed survey indicates your consent for use of the answers you supply. All participants will be United States occupational therapists or registered occupational therapists. Participants will include five hundred occupational therapists that will be selected randomly from the AOTA membership listing and who will receive a survey by mail. This survey was mailed out on July 1, 2003 and will need to have been filled out completely and returned by no later than July 29th, 2003 to be included in the study. The survey is comprised of 16 items including some personal demographic items and will take approximately 10 minutes to complete. Completing this survey is voluntary and the survey is anonymous. Do not put your name anywhere on the survey. The potential risks in taking this survey include the small amount of time needed to complete this survey and any discomfort that you may feel if you are completing home modification/barrier free designs without extensive training. The survey has been designed to allow its participants to share any relevant information you are willing to share in a non-threatening manner. Please respond to each question by circling the appropriate number or response. Your candid response to the items will enhance the validity of this research. Once you have completed the survey please return it by placing the completed forms inside the self addressed, postage free envelope provided. If you choose not to participate, please return the survey in envelope provided or discard. If you have any questions, you may contact Dr Debra Hazel at 269-387-7239 or Christian Petrovich at 269-568-5683. You may also contact the Chair, Human Subjects Institutional Review Board 269-387-8293 or the Vice President for Research 269-387-8298 if questions or problems arise during the course of the study.

I appreciate your consideration for participating in this project. Your participation is valuable and will be used to examine how occupational therapists view their role in relation to home modification and barrier free design and to ascertain what current trends are taking place in the area of home modification and barrier free design. If you would like to receive a copy of my abstract upon completion of this study email me at petrov20032003@yahoo.com.

This consent document has been approved for use for one year by the Human Subjects Institutional Review Board as indicated by the stamped date and signature of the board chair in the upper right corner. You should not participate in this project if the corner does not have a stamped date and signature or if the stamped date is older than one year.

Respectfully Yours,

Christian M. Petrovich OTR

Dr Debra Lindstrom Hazel OTR

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